The Besançon Stroke Registry: an acute stroke registry of 2,500 consecutive patients.

The purpose of this study was to estimate the frequency of various risk factors, courses and outcome of stroke subtypes in a large hospital-based stroke registry. The Centre Hospitalier Universitaire of Besançon is the only public hospital with a neurological department in the county to admit any unselected patient with an acute stroke. A prospective hospital-based registry using systematic computer coding of data was conducted. All patients were evaluated by standard testing (neuroimaging, Doppler ultrasonography and cardiac investigations). From 1987 to 1994, 2,500 stroke patients with a first-ever stroke were included in the Besançon Stroke Registry. There were 1,425 men (mean age 66.1 years) and 1,075 women (mean age 70.6 years). Ischemic stroke was present in 84% of the patients (cerebral infarction in 84.5% and transient ischemic attacks in 15.5%), primary intracerebral hemorrhage (PIH) in 14.2% and cerebral venous thrombosis in 1.8%. On the 1st day of the stroke 79.9% of the patients were admitted, 47.1% within 6 h. In addition, stroke severity was well correlated with the time of the patient's admission. Past medical history of hypertension was the major risk factor occurring in 55.8% of all patients, followed by smoking, atrial fibrillation, ischemic heart disease, hypercholesterolemia and diabetes mellitus. Clinical presentation was distributed according to classical patterns. The in-hospital mortality rate was 13.6% and was higher in patients with infarcts (13.7%) or PIH (25.6%). Logistic regression analysis determined independent predictive factors for death: deterioration at 48 h [odds ratio (OR) 10.1, 95% confidence interval (CI) 7.0-14.5], initial loss of consciousness (OR 4.5, 95% CI 3.1-6.4), age > 70 (OR 2.6, 95% CI 1.8-3.8), complete motor deficit (OR 1.9, 95% CI 1.3-2.8), major cognitive syndrome (OR 1.5, 95% CI 1.1-2.3), hyperglycemia at admission (OR 1.007, 95% CI 1.004-1.01), female gender (OR 0.7, 95% CI 0.5-0.9) and regressive stroke onset (OR 0.2, 95% CI 0.1-0.5). The Besançon Stroke Registry is a useful tool for the study of the risk factors, clinical features, and the course of strokes in an early phase.

Early CT signs in acute middle cerebral artery infarction: predictive value for subsequent infarct locations and outcome.

During the first hours after acute ischemic stroke, the CT usually shows no abnormalities. Therapeutic trials of ischemia in the middle cerebral artery (MCA) territory involves decision-making when the CT may not show obvious ischemic changes. We reviewed 100 consecutive patients, admitted within 14 hours after a first stroke. Selective criteria were clinical presentation with MCA ischemia and at least two CTs (1 initial and 1 control). All CTs were retrospectively analyzed by at least two physicians blinded to the patient's status. On the first CT, early signs were hyperdense MCA sign (HMCAS), early parenchymatous signs (attenuation of the lentiform nucleus [ALN], loss of the insular ribbon [LIR], and hemispheric sulcus effacement [HSE]), midline shift, and early infarction. Subsequent infarct locations were classified according to total, partial superficial (superior or inferior), deep, or multiple MCA territories. Clinical features, etiology, and Rankin scale were collected. There were 52 women (mean age 70.8). The CTs were performed at mean 6.4 hours (1 to 14 hours) and before the sixth hour in 62% of the patients. Early CT was abnormal in 94% of the cases, and the abnormalities found were an HMCAS in 22 patients, ALN in 48, LIR in 59, HSE in 69, midline shift in 5, and early infarct in 7. CT was normal in six patients where it was performed earliest (mean 4.5 hours) and in the oldest patients (mean age 80.1). Early parenchymatous CT signs were significantly associated with subsequent MCA infarct location and extension: ALN and deep infarct, HSE and superficial infarct, LIR and large infarct. HMCAS was never found in isolation and was always associated with the three other signs in extended MCA infarct. The presence of two or three signs (ALN, LIR, or HSE) was associated with extended MCA infarct (p < 0.001) and poor outcome (p < 0.001). Our findings suggest that CT frequently discloses parenchymal abnormalities during the first hours of ischemic stroke. Early signs allow the prediction of subsequent infarct locations; CT may provide a simple tool in evaluating the early prognosis of MCA infarction and thus may be useful in selecting better treatments.

Vascular ataxic hemiparesis: a re-evaluation.

Ataxic hemiparesis is commonly considered as one of the "typical" lacunar syndromes. Using the prospective stroke registries from Lausanne and Besançon, 100 patients were selected consecutively (73% men, 27% women; age 64.7 (SD 13.6) years) with a first stroke and ataxic hemiparesis (hemiparesis or pyramidal signs and ipsilateral incoordination without sensory loss). Brain CT or MRI was performed on all patients. A primary haemorrhage was present in 5%, an infarct in 72%, isolated leukoaraiosis in 9%, and no apparent abnormality in 14%. The locations of lesions were the internal capsule (39%), pons (19%), thalamus (13%), corona radiata (13%), lentiform nucleus (8%), cerebellum (superior cerebellar artery territory) (4%), and frontal cortex (anterior cerebral artery territory) (4%). The clinical features of ataxic hemiparesis with different locations were almost identical. Only minor associated signs allowed the localisation of the lesions (paraesthesiae with a lesion in the thalamus; nystagmus or dysarthria with a cerebellar or pontine location). Crural paresis with homolateral ataxia was seen only with cortical paramedian frontal lesions. Presumed hypertensive small artery disease was not always found, but was still the leading cause of stroke, being present in 59% of the patients and in 62% of those with small deep infarcts. A potential source of embolism (arterial or cardiac) was found in one fourth of the patients. Therefore no definite association can be made between ataxic hemiparesis and lacunar infarction. In particular, so called uncommon lesion locations may not be rare. After extensive investigations a diagnosis of lacunar infarct can be retained in only slightly more than half of the cases.

Hemorrhagic infarcts.

A review of hemorrhagic transformation after brain ischemia is presented. The pathological, clinical and radiological aspects are discussed with respect to recent studies. The different pathophysiological mechanisms (reperfusion, vascular rupture, size of infarction, timing of constitution) are reviewed. The role of the utilization of antithrombotic (anticoagulant and thrombolytic) agents in the production of hemorrhagic infarct is presented, and we propose a new classification of hemorrhagic infarct, based on the CT scan patterns.

[Comparison between x-ray computed tomography and magnetic resonance imaging after transient ischemic accidents]. / Comparaison du scanner X et de l'imagerie par résonance magnétique après des accès ischémiques transitoires.

We studied 18 patients with transient ischemic accidents (TIA) and normal CT scan during the first 24 hours. MRI was performed 9 days later on average. MRI revealed abnormalities in 10 patients (56 p. 100), but only 5 of them (27 p. 100) had lesions corresponding to TIAs, and in every case these were in the carotid territory. In the 7 patients with clinical signs of TIA in the vertebro-basilar territory, MRI was always negative. In 5 patients (27 p. 100), MRI showed abnormalities that were unrelated to TIA. This study suggests that MRI is of limited value in detecting brain tissue abnormalities and is perhaps not more sensitive than CT in vertebro-basilar TIA. However, in view of the small number of patients these results must be interpreted with caution.